Whitehead Law Firm, LLC

Estate Planning Data Form

Data Form 1

This form can be filled out and brought to your attorney's office at your first meeting. 

CONFIDENTIAL

PERSONAL AND FAMILY INFORMATION

CLIENT

Name:________________________________________________________
Address:______________________________________________________
_____________________________________________________________
Phone:____________________________
Email address: _______________________

Date of Birth:_______________

Social Security No.:______________________
Occupation:____________________________________________________
Business Address:_________________________________________________
_____________________________ Phone:__________________________

SPOUSE

Name:________________________________________________________
Address:______________________________________________________
_____________________________________________________________
Phone:____________________________
Email address: _______________________

Date of Birth:_______________

Social Security No.:______________________

Occupation:____________________________________________________
Business Address:_________________________________________________
_____________________________ Phone:__________________________
 CHILDREN

Child's Name:__________________________________________________
Address:______________________________________________________
_____________________________ Phone:__________________________
Occupation:___________________________________________________
Business Address:_______________________________________________
_____________________________ Phone:__________________________
Date of Birth:_______________ Social Security No.:______________
Spouse's Name:_______________ Occupation:_______________________
Names and ages of child's children:
_____________________________________________ Age:____________
_____________________________________________ Age:____________
_____________________________________________ Age:____________
_____________________________________________ Age:____________
_____________________________________________ Age:____________


Child's Name:__________________________________________________
Address:______________________________________________________
_____________________________ Phone:__________________________
Occupation:___________________________________________________
Business Address:_______________________________________________
_____________________________ Phone:__________________________
Date of Birth:_______________ Social Security No.:______________
Spouse's Name:_______________ Occupation:_______________________
Names and ages of child's children:
_____________________________________________ Age:___________
_____________________________________________ Age:___________
_____________________________________________ Age:___________
_____________________________________________ Age:___________
_____________________________________________ Age:___________

Child's Name:__________________________________________________
Address:______________________________________________________
_____________________________ Phone:__________________________
Occupation:___________________________________________________
Business Address:_______________________________________________
_____________________________ Phone:__________________________
Date of Birth:_______________ Social Security No.:______________
Spouse's Name:_______________ Occupation:_______________________
Names and ages of child's children:
_____________________________________________ Age:___________
_____________________________________________ Age:___________
_____________________________________________ Age:___________

OTHER DEPENDENTS

Give name, address, age, relationship, and annual cost of support.
____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

MISCELLANEOUS INFORMATION

Are you a citizen of the United States? Yes ___________No ________
Is your spouse a citizen of the United States? Yes _______No _____
Do you presently have a will? Yes _____________No ________________
Do you presently have a trust? Yes ____________No ________________
Are any children or grandchildren adopted? Yes ________ No _______
Do you and your spouse have a pre-nuptial agreement? Yes ___No ___
Have you and your spouse ever lived in any of the following states: Arizona,California, Idaho, Louisiana, New Mexico, Nevada, Puerto Rico, Texas, orWashington? Yes _____________ No _______________
Are there any significant health problems you, your spouse or anyone dependingon you for support may have?  Yes___  No ____

GUARDIAN / CONSERVATOR FOR MINORS.   If you have minor children livingwhen you die, whom do you want to raise them and be their guardian?
First Choice:
Name _______________________ Relationship _____________
Address ________________________________________________

If he or she is unable or unwilling to serve, who should serve?

Name _______________________ Relationship _____________
Address ________________________________________________

PERSONAL REPRESENTATIVE.  Whom do you want to serve your estate as personal representative (executor) in the probate of any assets not held in trust?  This can be the same person as your trustee.

FIRST CHOICE:
Name _______________________ Relationship _____________
Address _______________________________________________

SECOND CHOICE:  If he or she isunable or unwilling to serve, who should serve?

Name _______________________ Relationship _____________
Address ________________________________________________

____________________________________________________________
What is his/her relationship to you? _____________________________
 

POWER OF ATTORNEY - MEDICAL

If you need to have medical decisions made but are unable to make them yourself, who should make them?

First Choice:
Name _______________________ Relationship _____________
Address _______________________________________________

SECOND CHOICE:  If he or she is unable or unwilling to serve, who should serve?

Name _______________________ Relationship _____________
Address ________________________________________________
 

POWER OF ATTORNEY - FINANCIAL

If you need to have financial decisions made but are unable to make them yourself, who should make them?

First Choice:
Name _______________________ Relationship _____________
Address _______________________________________________

SECOND CHOICE:  If he or she is unable or unwilling to serve, who should serve?
Name _______________________ Relationship _____________
Address ________________________________________________

DISTRIBUTIONS TO BENEFICIARIES AFTER YOUR DEATH

If you have children: Do you want them to receive their inheritance in lump sum at age ____, or in installments at the following specified ages ___________________________________________________

If one of your children dies before you: Does that child's inheritance go (1)____ to his/her children, or (2) ____ to your other living children?

Do you wish to make any special gifts of property or cash to any individuals?  Yes _______ No _______

Specify their name, address, and the item or amount:
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Do you wish to make any gifts to your church or other charitable organizations?
Yes ______ No ______
If so, is the gift to be effective at (1) ____ your death, (2)____ you and your spouse's death, (3) ____ minor child attaining the age of ____ years, or (4)____ other (specify)?
If making a charitable gift, provide the exact name of the organization, address, and percent or dollar amount of gift.
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Are there any relatives whom you specifically do not want to receive anything from your estate? Yes _____________ No ________
If so, whom?

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

Are there any debts that you wish to forgive? Yes _____ No _____
If so, whom, the present amount, and the amount to forgive (or all)?
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

After the death of you and your spouse, if any, and after all special gifts have been distributed, whom do you want to receive the rest of your estate?
In equal shares to children (check here)_____, or:

Name _________________ Relationship _______ Percentage _____
Name _________________ Relationship _______ Percentage _____
Name _________________ Relationship _______ Percentage _____
Name _________________ Relationship _______ Percentage _____

TRUSTEE - REVOCABLE LIVING TRUST 

If you decide to create a revocable living trust, who should serve as trustee after you and your spouse die?

FIRST CHOICE:
Name _______________________ Relationship _____________
Address _______________________________________________

If he or she is unable or unwilling to serve, who should serve?

SECOND CHOICE:  
Name _______________________ Relationship _____________
Address ________________________________________________

See the page on Revocable Living Trust.